DESCRIPTION (provided by investigator): Approximately 22 million people in Sub-Saharan Africa were HIV-infected in 2007. HIV-related stigma-"a process of devaluation of people ... with HIV/AIDS" (UNAIDS)-has been documented worldwide, and is associated with depression, low self-esteem, and suboptimal treatment outcomes. HIV-related stigma has been described as an important cause of concealment of HIV status, inconsistent condom use, and low uptake and retention in treatment programs, compromising prevention and control efforts. The WHO has suggested that expanded access to antiretroviral therapy (ART) may reduce stigma by changing perceptions about HIV. The proposed research evaluates this supposition in the Ugandan context: Since treatment rollout began, have stigma and negative social consequences of HIV diagnosis declined, and have they changed differentially for men and women? The specific aims are to assess the association between treatment access and 1) enacted stigma (discrimination), 2) disclosure of HIV serostatus to primary partner, and 3) marital dissolution. The proposed study utilizes data from the Rakai Health Sciences Program (RHSP) in southwestern Uganda. The study population includes an estimated 3,000 couples followed in 50 villages by the RHSP Rakai Community Cohort Study (RCCS) between 2001-2008 and approximately 1,400 adults receiving ART from RHSP with funding from the President's Emergency Plan for AIDS Relief (PEPFAR). The RHSP is an ideal setting to assess this important public health question, as provides rich sociodemographic, behavioral, and serologic data for a large representative community sample pre and post ART availability in rural Africa. Enacted stigma (Aim 1) is measured by questionnaire among adult HIV-clinic clients who have initiated ART. HIV sero-status disclosure (Aim 2) and marital dissolution (Aim 3) are assessed through annual RCCS questionnaires including time periods before and after ART, cross-checked between partner responses. Log binomial regression will be used to assess correlates of enacted stigma;results will be stratified by gender. Discrete-time survival analysis via pooled logistic regression will be used to examine the association between ART availability and HIV sero-status disclosure, as well as ART availability and marital dissolution. The proposed research will contribute to multiple CDC objectives described under "Healthy People in a Healthy World" and "Healthy People in Every Stage of Life". Findings on disclosure, martial dissolution, and enacted stigma in Rakai can be applied to reduce the impact of stigma on public health efforts to promote HIV testing, positive secondary prevention behaviors, and treatment utilization in a variety of settings. Ultimately, this research will contribute to the body of evidence supporting and guiding public health investments to improve psychosocial outcomes and quality of life for people living with HIV (Objective 25), increase HIV testing and sero-status disclosure, decrease HIV transmission through unprotected sexual intercourse (Objectives 7.1, 26, and 30), and improve uptake and retention in HIV treatment (Objective 24). PUBLIC HEALTH RELEVANCE: More than 22 million Africans are living with HIV, and many studies have documented significant negative health impacts of perceived HIV-related stigma, including depression, low self-esteem, and suboptimal treatment outcomes. In order to overcome stigma as a barrier to healthcare utilization, adherence to antiretroviral medication, secondary prevention, sero-status disclosure, and social support, more evidence is needed on the relationship between treatment availability and stigma in African settings. This study will inform public health strategies to reduce the impact of stigma on prevention and health-seeking behaviors.